Vaginal Hysterectomy Dispelling the Myths by mikeholy



Vaginal Hysterectomy: Dispelling the Myths
Geoff McCracken, MB BCh, BAO, MRCOG, Guylaine G. Lefebvre, MD, FRCSC
Department of Obstetrics and Gynecology, St. Michael’s Hospital, Toronto ON

Abstract                                                                      nous nous sommes penchés sur les quatre raisons les plus
                                                                              souvent invoquées pour rejeter le recours à l’hystérectomie
   Despite advances in minimally invasive surgery, most                       vaginale : (1) dimensions de l’utérus, (2) nulliparité et descente
   hysterectomies are still performed by laparotomy. The ratio of             utérine, (3) nécessité de procéder à une ovariectomie et (4)
   abdominal to vaginal hysterectomies ranges from 1:1 to 6:1 across          antécédents de chirurgie abdominopelvienne et de pathologie
   North America, and in Canada is approximately 3:1. The SOGC                extra-utérine.
   clinical practice guideline on hysterectomy states that the vaginal
   route should be considered for every hysterectomy; if it is                D’autres recherches s’avèrent nécessaires afin d’évaluer et de
   assumed that most surgeons would try to follow accepted                    démystifier les obstacles à l’exécution d’une hystérectomie
   guidelines, vaginal hysterectomy is presumably being considered            minimalement effractive. Nous recommandons l’élaboration de
   and excluded.                                                              programmes de préceptorat à l’intention des chirurgiens en
                                                                              gynécologie, et ce, pour tenter d’abaisser la proportion
   The evidence is compelling that vaginal hysterectomy is the                d’hystérectomies abdominales, par rapport aux hystérectomies
   approach of choice for benign pathology. The cited                         vaginales.
   contraindications to vaginal hysterectomy are often
   unsubstantiated. In this commentary we examine the four reasons       J Obstet Gynaecol Can 2007;29(5):424–428
   most often cited for avoiding a vaginal hysterectomy: (1) uterine
   size, (2) nulliparity and uterine descent, (3) need for
   oophorectomy, and (4) previous abdominopelvic surgery and
   extrauterine disease.
                                                                              ysterectomy is a common operation, with up to 20%
    More research is necessary to evaluate and demystify the barriers
   to performing minimally invasive hysterectomy. We recommend
                                                                         H    of women undergoing the procedure by the age of 60.1
   that preceptorship programs be developed for gynaecologic             Most hysterectomies are performed abdominally. The ratio
   surgeons in an attempt to decrease the ratio of abdominal to
   vaginal hysterectomies.
                                                                         of abdominal to vaginal hysterectomy ranges from 1:1 to
                                                                         6:1 across North America, and is approximately 3:1 in
Résumé                                                                   Canada.
   Malgré les percées dans le domaine de la chirurgie minimalement       In Canada in 1998–1999, 462 hysterectomies were per-
   effractive, la plupart des hystérectomies sont toujours effectuées
   par laparotomie. La proportion d’hystérectomies abdominales, par
                                                                         formed per 100 000 women. The rate of hysterectomy var-
   rapport aux hystérectomies vaginales, varie de 1:1 à 6:1 en           ies by province from a low of 434/100 000 women over age
   Amérique du Nord; au Canada, elle se situe à environ 3:1. La          35 in British Columbia to a high of 750/100 000 women in
   directive clinique de la SOGC sur l’hystérectomie indique que la
   voie vaginale devrait être envisagée pour chacune des                 Newfoundland.2,3
   hystérectomies pratiquées; si l’on présume que la plupart des
   chirurgiens tentent de respecter les directives cliniques d’usage,
                                                                         A recent Cochrane review of surgical approach to hysterec-
   on doit donc en venir à la conclusion que l’hystérectomie vaginale    tomy for benign gynaecological disease, involving 3643
   est d’abord envisagée pour ensuite être mise de côté.                 women in 27 trials, concluded that the vaginal approach is
   Selon les données dont nous disposons, l’hystérectomie vaginale       preferred to the abdominal approach. When vaginal hyster-
   constitue de toute évidence l’approche à privilégier en présence
   d’une pathologie bénigne. Les contre-indications qui sont
                                                                         ectomy is not possible, laparoscopic hysterectomy may
   mentionnées en ce qui a trait à l’hystérectomie vaginale s’avère      avoid the need for an approach by laparotomy.4 The SOGC
   souvent sans fondement. Dans le cadre du présent commentaire,         clinical practice guideline on hysterectomy states that the
                                                                         vaginal route should be considered for every hysterectomy
                                                                         done for benign disease, but qualifies this by stating that the
                                                                         selected approach depends on the surgeon’s expertise, the
                                                                         indication for surgery, the nature of disease, patient charac-
Key Words: Vaginal hysterectomy, abdominal hysterectomy,                 teristics, and the patient’s preference.5
laparoscopic hysterectomy
                                                                         Why the abdominal route remains the predominantly used
Competing Interests: None declared.
                                                                         approach for hysterectomy in Canada is a matter for debate,
Received on May 26, 2006
                                                                         especially in the light of strong evidence that the vaginal
Accepted on November 14, 2006                                            route results in fewer complications, shorter hospital stays

424   l MAY JOGC MAI 2007
                                                                                         Vaginal Hysterectomy: Dispelling the Myths

and convalescence, lower hospital costs, and better quality      We have performed vaginal hysterectomy without added
of life outcomes6–9; in addition, the vaginal route carries      complication in the presence of a uterus weighing as much
cosmetic benefit.                                                as 1 kg. Morcellation of the uterus is easily accomplished
Several theories may explain the disparity between scientific    once the uterine vessels are secured, although it requires
evidence and clinical practice. First, many surgeons believe     patience and fresh blades for the scalpel so that the incisions
that nulliparity, previous pelvic surgery (including Caesar-     into the myometrium are smooth. The scalpel blade should
ean section), a need for oophorectomy, pathology outside         be kept in view at all times to minimize the risk of small
the uterus (endometriosis and adhesions), and uterine            bowel injury, especially as the fundus nears. We decide
enlargement are contraindications to using a vaginal             whether a vaginal approach will be possible based on our
approach for hysterectomy. This results in a high propor-        impression of the lateral bulk of the uterus. A uterus that is
tion of abdominal or laparoscopically assisted hysterecto-       positioned high in the pelvis and extends laterally to the pel-
mies being performed when the procedure could be per-            vic sidewalls may not permit a vaginal approach to the uter-
formed by the vaginal route. Second, surgeons may choose         ine arteries. On the other hand, a large but mobile uterus
the abdominal route on the basis of their experience, com-       that does not extend to the pelvic sidewalls will allow the
fort, and preference, and then proceed to justify their choice   surgeon to reach laterally and clamp the uterine vessels,
with the listed contraindications.                               after which morcellation is readily accomplished. In our
                                                                 experience, the position and mobility of the uterus are more
The objective of this commentary is to review the literature     critical than its size in making the decision regarding route
and elucidate the misconceptions that are held by some           of approach. When in doubt, it is logical to approach the
gynaecologists regarding contraindications and concerns in       uterus with a vaginal colpotomy. If it is possible to enter the
performing vaginal hysterectomy. We will examine the con-        posterior cul de sac, then anterior colpotomy should be
ditions most cited as reasons for avoiding a vaginal hyster-     attempted. If this is also possible, then the uterosacral, car-
ectomy and review the evidence supporting the use of the         dinal and proximal utero-ovarian ligaments should be
vaginal route in these clinical settings.                        clamped serially on either side. Morcellation can then be
                                                                 accomplished to deliver the uterus. If colpotomies are not
                                                                 possible, or the uterine vessels cannot be secured as the sur-
                                                                 gery progresses, then an abdominal approach is required.
1. Uterine Size
There is no consensus on the uterine size or weight that         2. Nulliparity and Lack of Uterine Descent
would preclude undertaking a vaginal hysterectomy. A nor-        Nulliparity and minimal uterine descent are often cited by
mal uterus weighs approximately 100 g, whereas a uterus of       gynaecologists in justifying the need for an abdominal
12 weeks’ gestational size weighs approximately 280 g. The       approach to hysterectomy. A number of studies have con-
American College of Obstetricians and Gynecologists has          firmed that it is safe to perform a vaginal hysterectomy in
stated that vaginal hysterectomy is indicated for patients       the presence of minimal or no uterine descent; the only
with a mobile uterus of less than 12 week’s gestational          associated concern is that the risk of operative hemorrhage
size,10 but much larger organs can also be removed vagi-         appears to be increased in the presence of both uterine
nally. Studies comparing the outcome of abdominal hyster-        enlargement and minimal descent.20–22
ectomy and vaginal hysterectomy in the presence of an            In practice, a lack of uterine mobility and less than two
enlarged uterus have demonstrated that vaginal hysterec-         fingerbreadths of vaginal access are more significant con-
tomy is associated with less febrile morbidity, less reduction   siderations with regard to operability than is nulliparity.
in hematocrit, less requirement for narcotic use, and shorter    These variables are sometimes difficult to gauge preopera-
hospital stay, with no difference in intraoperative              tively, and are likely best assessed when the patient is anaes-
complications.11–13                                              thetized prior to commencing surgery. In most patients the
Several strategies, such as bisection, wedge morcellation,       uterosacral and cardinal ligaments are relatively accessible
and coring, have been shown to facilitate vaginal hysterec-      vaginally, allowing further descent of the uterus as the sur-
tomy in the presence of an enlarged uterus, with no increase     gery progresses. If posterior colpotomy is not possible and
in morbidity.14–18 With these options in mind, Davies et al.     the ligaments are inaccessible, it is appropriate to convert to
have estimated that the overall vaginal hysterectomy rate        a laparoscopic or laparotomy approach. There is no
could be increased by 11.6% if the uterus is enlarged to the     increase in complications with this initial attempt at vaginal
size of a 10 week pregnancy, by 24.4% if enlarged to 14          hysterectomy. Using this approach, up to 99% of planned
weeks, and by 30.4%, if enlarged to 18 weeks’ gestational        vaginal hysterectomies could be completed vaginally.20 The
size.19                                                          patient should be made aware before surgery that

                                                                                                     MAY JOGC MAI 2007 l       425

intraoperative conversion either to laparoscopy or                   hysterectomy, regardless of approach; there is an increased
laparotomy may be required.                                          risk with the laparoscopic approach as well, and no
                                                                     statistical difference in risk of bladder entry between the
In cases where hysterectomy cannot be completed vagi-
                                                                     abdominal and vaginal routes.26 We suggest that sharp dis-
nally, it is quite feasible to place a sponge within a surgical
                                                                     section for bladder reflection during a vaginal hysterectomy
glove in the lower vagina and then proceed with a laparos-
                                                                     is preferable to blunt dissection in preventing accidental
copy. The gloved sponge will prevent escape of CO2
                                                                     cystotomy, as is the case at laparotomy. It has been our
through the vagina, and the procedure can be completed
                                                                     experience that damage to the bladder in women with a
                                                                     previous CS is usually easier to avoid during vaginal hyster-
                                                                     ectomy than during abdominal hysterectomy, because the
3. Need for Oophorectomy
                                                                     initial dissection plane is below any bladder scarring from
Bilateral salpingo-oophorectomy (BSO) is the procedure
                                                                     the CS.
most commonly performed concurrent with hysterectomy,
and most are performed by the abdominal route. Many sur-             Extrauterine pathology, such as endometriosis and pelvic
geons are reluctant to attempt BSO during vaginal hysterec-          inflammatory disease, is often cited as the reason for
tomy because of concerns about decreased surgical access             favouring an abdominal approach to hysterectomy. The
and visibility. However, most ovaries are visible and readily        surgical difficulty that extrauterine pathology may cause is
accessible during vaginal surgery, and it is generally safe to       often exaggerated; in the majority of patients, these condi-
perform BSO at the time of vaginal hysterectomy.22,23 Up to          tions should not be considered a contraindication to vaginal
97.5% of prophylactic oophorectomies can be completed                surgery.6,25,27 Review of previous diagnosis and operative
vaginally.24 It can be concluded therefore that in the vast          reports is recommended before choosing the route of
majority of cases prophylactic oophorectomy will be per-             hysterectomy.
formed successfully regardless of the route of hysterec-             When the preoperative history and examination findings
tomy. In cases where prophylactic oophorectomy is per-               suggest that there are extensive adhesions from previous
formed because the patient is at high risk for developing            surgery or significant extrauterine pathology, then laparo-
ovarian or tubal malignancies, it may be prudent to consider         scopic evaluation may be useful in determining the severity
a laparoscopically assisted vaginal hysterectomy in order to         of the pathology. If the pathology is absent or minimal, the
obtain peritoneal washings and to ensure that all adnexal tis-       surgeon may then proceed with vaginal hysterectomy. If the
sue is removed. In the majority of cases, however, a vaginal         laparoscopic assessment shows moderate pathology but the
approach is reasonable when there is no increased risk of            posterior cul de sac is accessible, laparoscopic assistance
malignancy or recurrent disease. If BSO cannot be com-               may be appropriate. Severe pathology or an obliterated cul
pleted vaginally as intended, and it is essential that BSO be        de sac may require an abdominal approach; the choice of
performed, it is feasible to perform laparoscopic BSO                approach is generally based on individual surgical experi-
intraoperatively. The pneumoperitoneum can be main-                  ence and comfort.28 In the presence of severe pelvic disease
tained by placing a surgical glove filled with sponges inside        the benefits of quicker recovery from laparoscopy should
the vagina; this also facilitates vaginal retrieval of the ovaries   be weighed against the higher incidence of major complica-
before closure of the vaginal vault. Alternatively, the vault        tions associated with abdominal hysterectomy.29
may be closed and the ovaries retrieved using endoscopic
bags after laparoscopic BSO.                                         THE CASE FOR VAGINAL HYSTERECTOMY
                                                                     Most cholecystectomies in Canada are performed without
4. Previous Abdominopelvic Surgery and
                                                                     laparotomy, and general surgeons continue to expand their
Extrauterine Disease
                                                                     minimally invasive surgical capabilities. Although gynae-
The wisdom of performing vaginal hysterectomy in a                   cologists were the first surgeons to use laparoscopy com-
patient with previous pelvic surgery has been debated for            monly, the expansion of their minimally invasive surgical
many years. In a 1973 review of 621 hysterectomies,                  skills seems to have stalled.
Coulam et al. concluded that previous pelvic surgery was
not a contraindication to vaginal surgery.25 However, in             The evidence is compelling that the vaginal approach is to
practice previous pelvic surgery is cited as the reason for          be preferred when considering hysterectomy for benign
choosing abdominal over vaginal hysterectomy in 28% of               pathology. Furthermore, many of the contraindications to
cases.19 Caesarean section (CS) is commonly recorded as              vaginal hysterectomy described by gynaecologists are
the reason for performing abdominal rather than vaginal              unsubstantiated.
hysterectomy. However, a history of previous CS is a signif-         An abdominal hysterectomy is the preferred approach in
icant risk for accidental cystotomy at the time of                   some situations. In situations where technical difficulty is

426   l MAY JOGC MAI 2007
                                                                                              Vaginal Hysterectomy: Dispelling the Myths

expected it is acceptable to attempt a vaginal route, and sub-   REFERENCES
sequent conversion to a laparoscopic hysterectomy or to           1. Royal College of Obstetricians and Gynaecologists. National
laparotomy should not be considered a complication but a             Evidence-Based Clinical Guidelines. The management of menorrhagia in
                                                                     secondary care. January 1999.
necessary step to complete the proposed surgery. The sub-
                                                                  2. National Center for Health Statistics. National Hospital Discharge Survey,
stitution of the laparoscopic approach for vaginal surgery           1997. CD-ROM. Washington, DC: National Center for Health Statistics.
has no benefits; on the contrary, there is a longer operating     3. Canadian Institute for Health Information. Statistics Canada Health
time and greater hospital costs associated with                      Reports, Vol 12, No 2.2000.
laparoscopically assisted vaginal hysterectomy than with          4. Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical
vaginal hysterectomy.4,29 Laparoscopic hysterectomy is               approach to hysterectomy for benign gynaecological disease. Cochrane
                                                                     Database Syst Rev. 2006 Apr 19;(2):CD003677
indicated if it avoids the need for laparotomy. The recent
report of Thiel and Kamencic advocated day surgery for            5. Lefebvre G, Allaire C, Jeffrey J, Vilos G. Hysterectomy. SOGC Clinical
                                                                     Practice Guidelines, No. 109, January 2002. J Obstet Gynaecol Can
total laparoscopic hysterectomy (TLH).30 They concluded              2002;24(1):37–48.
that TLH was more cost-effective than vaginal hysterec-           6. Kovac SR. Guidelines to determine the route of hysterectomy. Obstet
tomy; the major reason for the cost saving was the short             Gynecol 1995; 85:18–23.
mean postoperative stay of 354 minutes, resulting from            7. Summitt RL Jr, Stovall TG, Steege JF, Lipscomb GH. A multicenter
reduced postoperative pain. We suggest that the short post-          randomized comparison of laparoscopically assisted vaginal hysterectomy
                                                                     and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet
operative stay resulting from the minimally invasive                 Gynecol 1998; 92:321–6.
approach can also apply to the vaginal approach.                  8. Dicker RC, Greenspan JR, Strauss LT, Cowart MR, Scally MJ, Peterson
                                                                     HB, et al. Complications of abdominal and vaginal hysterectomy among
Preparing the patients and anticipating their likely recovery        women of reproductive age in the United States. The Collaborative Review
time have an important effect on postoperative length of             of Sterilization. Am J Obstet Gynecol 1982;144:841–8.

stay. The assertion that TLH is followed by less bruising         9. Van den Eeden SK, Glasser M, Mathias SD, Colwell HH, Pasta DJ, Kunz
                                                                     K. Quality of life, health care utilization, and cost among women
and less ischemic pain than vaginal hysterectomy is debat-           undergoing hysterectomy in a managed-care setting. Am J Obstet Gynecol
able.30 On the contrary, electrocautery at the time of TLH           1998;178:91–100.
may cause more pain than the ligation of pedicles at vaginal     10. American College of Obstetrician and Gynecologists. Quality assurance in
hysterectomy because of lateral thermal damage. A short              obstetrics and gynecology. Washington (DC): The College; 1989.
postoperative length of stay following TLH is in part due to     11. Unger JB Vaginal hysterectomy for the woman with a moderately enlarged
having experienced surgeons and to prophylactic use of               uterus weighing 200 to 700 grams. Am J Obstet
antiemetics and analgesia, which should also be available for
women undergoing vaginal hysterectomy.                           12. Doucette RC, Sharp HT, Alder SC. Challenging generally accepted
                                                                     contraindications to vaginal hysterectomy. Am J Obstet Gynecol
We feel that a lack of training in vaginal surgery ultimately
results in gynaecologists becoming reluctant to perform          13. Harris WJ. Early complications of abdominal and vaginal hysterectomy.
                                                                     Obstet Gynecol Surv 1995;50:795–805.
vaginal hysterectomy. We therefore recommend that
                                                                 14. Kammerer-Doak D, Mao J. Vaginal hysterectomy with and without
preceptorship programs be developed for surgeons already             morcellation: the University of New Mexico hospital’s experience. Obstet
in practice, and that access to vaginal surgery be facilitated       Gynecol 1996; 88:560–3.
for residents wherever possible, because we feel that such       15. Magos A, Bournas N, Sinha R, Richardson RE, O’Connor H. Vaginal
steps are key to increasing the number of hysterectomies             hysterectomy for the large uterus. Br J Obstet Gynaecol 1996;103:246–51.
attempted vaginally. This should lead to the ideal situation     16. Benassi L, Rossi T, Kaihura CT, Ricci L, Bedocchi L, Galanti B, et al.
in which every gynaecologist is capable of performing                Abdominal or vaginal hysterectomy for the enlarged uteri: a randomized
vaginal hysterectomy, laparoscopic hysterectomy, and                 clinical trial. Am J Obstet Gynecol 2002;187:1561–5.
abdominal hysterectomy. In this situation, patients under-       17. Kovac SR Intramyometrial coring as an adjunct to vaginal hysterectomy.
going hysterectomy would have the procedure that is                  Obstet Gynecol 1986;67(1):131–6.
appropriate for them, rather than the procedure their gynae-     18. Grody MH. Vaginal hysterectomy: the large uterus. J Gynecol Surg
cologist is able to perform. In 1934, N. S. Heaney stated, “it       1989;5:301–12.
is [my] purpose . . . to show again how low the mortality and    19. Davies A, Vizza E, Bournas N, O’Connor H, Magos A. How to increase the
morbidity of vaginal hysterectomy may be with the hope               proportion of hysterectomies performed vaginally. Am J Obstet Gynecol.
                                                                     1998; 179(4):1008–12.
that this operation may find a place in the operative arma-
mentarium of every gynecologist.”31 More than half a             20. Figueiredo O, Figueiredo EG, Figueiredo PG, Pelosi MA 3rd, Pelosi MA.
                                                                     Vaginal removal of the benign nonprolapsed uterus: experience with 300
century later, it is our professional responsibility to create       consecutive operations. Obstet Gynecol 1999;94(34):348–51.
opportunities for gynaecologic surgeons to maintain and
                                                                 21. Miskry T, Magos A. Randomized, prospective, double-blind comparison of
upgrade their surgical skills. Canadian women expect no              abdominal and vaginal hysterectomy in women without uterovaginal
less.                                                                prolapse. Acta Obstet Gynecol Scand 2003;82(4):351–8.

                                                                                                              MAY JOGC MAI 2007 l             427

22. Sheth SS. The scope of vaginal hysterectomy. Eur J Obstet Gynecol Reprod     27. Kovac SR, Cruikshank SH, Retto HF. Laparoscopy-assisted vaginal
    Biol 2004;115:224–30.                                                            hysterectomy. J Gynaecol Surg 1990;6:185–93.
23. Kovac SR, Cruikshank SH. Guidelines to determine the route of                28. Kovac SR. Clinical opinion: guidelines for hysterectomy. Am J Obstet
    oophorectomy with hysterectomy. Am J Obstet Gynecol 1996;175:1483–8.             Gynecol 2004;191:35–40.
24. Davies A, O’Connor H, Magos AL. A prospective study to evaluate
                                                                                 29. Garry R, Foutain J, Mason S, Hawe J, Napp V, Abbott J, et al. The
    oophorectomy at the time of vaginal hysterectomy. Br J Obstet Gynaecol
                                                                                     eVALuate study: two parallel randomised trials, one comparing laparoscopic
                                                                                     with abdominal hysterectomy, the other comparing laparoscopic with
25. Coulam CB, Prattt JH. Vaginal hysterectomy: Is previous pelvic operation a       vaginal hysterectomy. BMJ 2004;328:129–33.
    contraindication? Am J Obstet Gynecol 1973; 116(2): 252–8.
                                                                                 30. Thiel JA, Kamencic H. Assessment of costs associated with outpatient total
26. Rooney CM, Crawford AT, Vassallo BJ, Kleeman SD, Karram MM. Is                   laparoscopic hysterectomy. J Obstet Gynaecol Can 2006;28:794–8.
    previous cesarean section a risk for incidental cystotomy at the time of
    hysterectomy? A case-controlled study. Am J Obstet Gynecol                   31. Heaney NS. A report of 565 vaginal hysterectomies performed for benign
    2005;193(6):2041–4.                                                              pelvic disease. Am J Obstet Gynecol 1934;28:751–5.

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